Madhya Pradesh

StateCommission

A/17/118

STAR HEALTH & ALLIED INSURANCE CO. LTD. - Complainant(s)

Versus

SHIBU GEORGE - Opp.Party(s)

SH. PRANAY SAXENA

13 Feb 2023

ORDER

M. P. STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,                         

                             PLOT NO.76, ARERA HILLS, BHOPAL

 

                                      FIRST APPEAL NO. 118 OF 2017

(Arising out of order dated 26.12.2016 passed in C.C.No.697/2011 by District Commission, Indore)

 

1. STAR HEALTH & ALLIED INSURANCE

    COMPANY LIMITED, NO.1, NEW TANK ROAD,

    VALLUVARKOTTAM HIGH ROAD,

    NUNGAMBAKKAM, CHENNAI-34.

 

2. STAR HEALTH & ALLIED INSURANCE CO.LTD.

    BRANCH OFFICE INDORE-2,

    303-304, GOLD ARCADE, 3^RD FLOOR,

    NEW PALASIYA, OPP.CURE WELL HOSPITAL,

    INDORE (M.P.)                                                                                                      … APPELLANTS.

 

Versus

 

SHIBU GEORGE,

A-41, ABHINANDAN NAGAR,

SUKHLIYA, INDORE,

THROUGH M/S FAIR SKY TOURS & TRAVELS,

B-6, ALANKAR CHAMBERS, A-2, RATLAM KOTHI,

A.B.ROAD, INDORE (M.P.)                                                                                       … RESPONDENT.                                

                                 

BEFORE :

            HON’BLE SHRI JUSTICE SHANTANU S. KEMKAR   :  PRESIDENT

           HON’BLE SHRI D. K. SHRIVASTAVA                         :  MEMBER

            HON’BLE DR. (MRS) MONIKA MALIK                         :  MEMBER              

 

COUNSEL FOR PARTIES :

                Ms. Priyanka Kupade for Shri Ajay Dubey, learned counsel for the appellant.

           None for the respondent.             

 

                                              O R D E R

                                       (Passed on 13.02.2023)

                   The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member:

           

                   This appeal by the opposite parties/appellants (hereinafter referred to as ‘appellants’) is directed against the order dated 26.12.2016 passed by the District Consumer Disputes Redressal Commission, Indore (for short ‘District Commission’) in C.C.No.697/2011, whereby the complaint

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filed by the complainant/respondent (hereinafter referred to as ‘respondent’) has been partly allowed.

2.                Briefly put, facts of the case are such that the respondent, for himself and his family members had obtained ‘Family Health Optima Mediclaim’ Insurance Policy no. P/201115/01/2010/002163 from the appellant no.2 for sum insured of Rs.3,00,000/- for the period w.e.f. 17.10.2009 to 16.10.2010. The respondent who had already suffered from heart disease, suffered from cough and dyspnea and the treating doctor referred him to the CHL Apollo Hospital, Indore, where he was admitted on 11.01.2010 and was discharged on 14.01.2010. He incurred Rs.34,636/- as expenses in his treatment. The claim form was submitted with the appellants. The appellants rejected the claim on the ground that the insurance company is not liable to indemnify treatment expenses towards pre-existing ailment, before completion of 4 policy years. The respondent however, submitted that he was admitted in the hospital for treatment of cough and dyspnea and not for the treatment of heart disease.  The complainant/respondent therefore alleging deficiency in service on part of appellants, filed a complaint seeking claim amount with compensation and costs.

3.                The appellants contested the complaint stating that as per terms and conditions of the policy, if the insured, prior to obtaining the policy was

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suffering from any ailment, the claim is not payable, uptil 4 policy years. Since the policy obtained by the respondent was running in its second year, the claim is not payable for previous pre-existing disease and therefore the claim of the respondent was repudiated. The appellants have not committed any deficiency in service. It is therefore prayed that the complaint be dismissed.

4.                The District Commission partly allowed the complaint and directed the appellants-insurance company to pay to the complainant/respondent claim amount of Rs.34,636/- with interest @ 9% p.a. from the date of filing of claim, till payment within two months failing which the amount shall carry interest @ 12% p.a. In addition costs of Rs.2,000/- is also awarded.

5.                Heard. 

6.                Learned counsel for the appellants argued that the District Commission ignored the important fact that claim of the respondent was rejected by the appellant on the basis that he was suffering from C.O.A.D prior to taking the insurance policy. The full form of COAD is ‘Chronic Obstructive Airway Disease’. The discharge summary of CHL Apollo Hospital shows that he was suffering from COAD since 20 years and this disease was not disclosed with the appellants-insurance company by the respondent while obtaining the policy. The appellant as per terms and

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conditions of the policy has rightly rejected the claim of the respondent. The claim for pre-existing disease/condition as defined in the policy is not payable until 48 months of continuous coverage has elapsed, since inception of the policy. The District Commission has thus erroneously passed the impugned order, which deserves to be set-aside.

7.                We find that the District Commission has held that the respondent has filed claim for expenses incurred in treatment of cough, dyspnea and fever which is related to infection in lungs whereas the previous ailment COAD (Coronary Artery Disease) is clearly related to heart disease and has no relevance with the present ailment. It is thus held that the repudiation of the claim of the respondent, by the appellants amounts to deficiency in service.

8.                We however, find that Annexure B, is a discharge summary issued by the CHL Apollo Hospitals, Indore in which the respondent was diagnosed as a case of COAD/Smoker. In the history, it has been mentioned that Mr. Shibu George, 42yrs male is a chronic smoker, a known case of COAD since 20 years, presented with complaint of cough, dyspnea off and on since 7 days. There is history of fever. Presently admitted for further management. Full form of COAD is Chronic Obstructive Pulmonary Disease. However, the District Commission has wrongly considered that it

 

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relates to heart disease.  The District Commission has overlooked this document which is available in the record.

9.                We find that Annexure D-1 is a policy document, in which it has specifically been mentioned that “The company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of: Pre-Existing Disease as defined in the policy, until 48 months of continuous coverage have elapsed, since inception of the first policy with the Company”.

10.              Annexure E is the claim rejection letter dated 16.02.2010 in which the ground for rejection is mentioned as “Patient is a known case of COAD since 20 years as mentioned by treating doctor in discharge summary. Since the present ailment had been existing even before commencement of insurance, Hence it is complication of PED.”

11.              To summarize, the respondent, who was a known case of COAD (Chronic Obstructive Pulmonary Disease) was admitted in CHL Apollo Hospitals, Indore for treatment of same and since it was a pre-existing ailment, when seen in relation to current policy, the claim regarding its treatment could become payable after 4 continuous policy years, as per policy terms and conditions. 

 

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12.              The appellants therefore have denied the respondent’s claim citing it as a complication of pre-existing disease.  The respondent has wrongly interpreted that his claim was denied on account of it being a claim arising out of treatment of heart ailment.  The subject claim was certainly with regard to COAD and was rejected by the appellants on the very ground that COAD (Chronic Obstructive Pulmonary Disease) is the pre-existing ailment in the respondent’s case and not CAD (Coronary Artery Disease) as has been alleged. Therefore, the complainant/respondent does not deserve to be granted relief in terms of the insurance claim with compensation and costs.

13.              The District Commission has further erred in misinterpreting the reasons for claim rejection.  Therefore, in view of the foregoing discussion, considering the facts and the circumstances of the case, the impugned order passed by the District Commission cannot be sustained and deserves to be set-aside. It is accordingly set-aside.

14.              This appeal filed by the appellant insurance company thus succeeds and is allowed with no order as to costs. 

 

 (JUSTICE SHANTANU S. KEMKAR)   (D. K. SHRIVASTAVA) (DR. MONIKA MALIK)                     

                  PRESIDENT                                     MEMBER                     MEMBER